Marcus Foundation

Background: Diabetes mellitus (DM) is a common comorbidity in patients hospitalized with an acute myocardial infarction (AMI), and, in some cases, the AMI hospitalization represents the first opportunity to recognize and treat DM. We sought to understand both the prevalence of incident DM and its rate of recognition among AMI patients without DM diagnosis on admission. Methods: Patients in a 24-site U.S. AMI registry had A1C assessed at a core lab, which was blinded to clinicians. Patients could also have A1C drawn for clinical purposes. We defined DM based on A1C≥6.5% or, if A1C level was missing, based on ≥2 fasting glucose levels ≥126 mg/dL or ≥1 fasting glucose ≥126 mg/dL AND glucose at presentation ≥200 mg/dL. DM was considered recognized if the patient received DM education during the hospitalization or a DM medication at discharge. Multivariable, hierarchical logistic regression examined factors associated with recognition. Treatment with DM medications was evaluated at 6-months after discharge. Results: Among 2854 AMI patients without known DM on admission, 287 patients (10.1%) had core lab-diagnosed DM. Among these, 198 (69%) were not recognized by the treating physicians. Median A1C of unrecognized patients was 6.7%, range of 6.5-12.3%. If the treating physician checked an A1C during the AMI, this was associated with a 17-fold increased odds of recognition (95% CI 6.0-50.2). Furthermore, if the A1C was checked and was ≥7% (vs. <7%), this was also associated with 17-fold increased odds of DM recognition (95% CI 6.3-47.1). Six months after discharge, only 6.8% of those not recognized as having DM during hospitalization had been initiated on DM medications vs. 71% of those recognized during the AMI (p<0.001). Discussion: Among AMI patients without known DM, 1 in 10 have underlying DM. Recognition of this remains sub-optimal, with fewer than 1 in 3 patients receiving DM education or medications at discharge. The majority of unrecognized patients are not initiated on therapy during follow-up, emphasizing the importance of recognition during the AMI hospitalization. Furthermore, the strongest predictor of recognition was A1C assessment during hospitalization, highlighting an important opportunity to improve the recognition of DM and, possibly, long-term glycemic control in patients hospitalized with AMI.

Performance feedback has facilitated the acquisition and maintenance of a wide range of behaviors (e.g., health-care routines, seat-belt use). Most researchers have attributed the effectiveness of performance feedback to (a) its discriminative functions, (b) its reinforcing functions, or (c) the combination of the two. In this study, we attempted to evaluate the relative contributions of the discriminative and reinforcing functions of performance feedback by comparing a condition in which the discriminative functions were maximized and the reinforcing functions were minimized (i.e., performance-specific instructions without contingent money) with one in which the reinforcing functions were maximized and the discriminative functions were minimized (i.e., contingent money with no performance-specific instructions). We compared the effects of these two conditions on the acquisition of skills involved in conducting two commonly used preference assessments. Results showed that acquisition of these skills occurred primarily in the condition with performance-specific instruction without contingent money, suggesting that the delivery of performance-specific instructions was critical to skill acquisition, whereas the delivery of contingent money had little effect.

In the current investigation, we evaluated the effects of open and closed economies on the adaptive behavior of 2 individuals with developmental disabilities. Across both types of economy, progressive-ratio (PR) schedules were used in which the number of responses required to obtain reinforcement increased as the session progressed. In closed-economy sessions, participants were able to obtain reinforcement only through interaction with the PR schedule requirements (i.e., more work resulted in more reinforcer access). In open-economy sessions, participants obtained reinforcers by responding on the PR schedule and were given supplemental (free) access to the reinforcers after completion of the session. In general, more responding was associated with the closed economy.

This study examined packing (pocketing or holding accepted food in the mouth) in 3 children who were failing to thrive or had inadequate weight gain due to insufficient caloric intake. The results of an analysis of texture indicated that total grams consumed were higher when lower textured foods were presented than when higher textured foods were presented. The gram intake was related directly to levels of packing. That is, high levels of packing were associated with higher textured foods and low gram intake, and low levels of packing were associated with lower textured foods and high gram intake. All participants gained weight when texture of foods was decreased. Packing remained low during follow-up for 2 participants even when the texture of food was increased gradually over time. These data are discussed in relation to avoidance, response effort, and skill deficit.

About the authors Jalma Marcus is president and Lana Liberto is vice-president, Marcus & Liberto, Inc., Dresher, Pa.

Pica is a life-threatening behavior displayed by many individuals with developmental disabilities. In the current study, automatic reinforcement maintained the pica of 3 participants. Following functional analyses of pica, response-effort manipulations were conducted in which the effort to obtain pica or alternative items was varied systematically. Several general relations emerged as a result of the study. First, levels of pica were reduced relative to baseline when alternative items were available independent of the effort required to obtain alternative items or pica. Second, increasing the effort for alternative items resulted in increases in pica relative to when effort for alternative items was low. Third, increasing response effort for pica produced reductions in pica relative to baseline when alternative items were unavailable. Fourth, the highest levels of pica occurred when the effort to engage in pica was low or medium and no alternative items were available. These findings are discussed in terms of the relative effects of quality of reinforcement and response effort on behavior.

Recent research findings suggest that idiosyncratic variables can influence the outcomes of functional analyses (E. G. Carr, Yarbrough, & Langdon, 1997). In the present study, we examined idiosyncratic environment-behavior relations more precisely after identifying stimuli (i.e., a particular toy and social interaction) associated with increased levels of problem behavior. Two children, an 8-year-old boy with moderate mental retardation and a 5-year-old boy with no developmental delays, participated. Results of functional analyses for both children indicated that idiosyncratic antecedent stimuli set the occasion for occurrences of problem behavior (hand biting or hand flapping) and that problem behavior persisted in the absence of social contingencies. Further analyses were conducted to identify specific components of the stimuli that occasioned problem behavior. Treatments based on results of the analyses successfully reduced self-injury and hand flapping.